USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 46
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Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
NOV 1 51963 AM
X PLACE OF DEATH
Suffolk (County )
Winthrop (City or Town)
No. Sturgis .... St.
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
234
§ (If death occurred in a hospital or institution, Bay View Nursing sHomeits NAME instead of street and number)
PHYSICIAN - IMPORTANT
NAME John E ...... Conway
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
44 Belcher St.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
. .. .. ... years.
1
months.
.days. In place of residence.
20 ... years.
months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEMarried
HEREBY CERTIFY,
That I attended deceased from
1063
how. 15
death is said to
have occurred on the date stated above, at
1:50 P.m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Pneumonia, bilateral
INTERVAL
12
BETWEEN
ONSET AND
DEATH
Juk
77
11 IF STILLBORN, enter that fact here.
Years.
. Months.
.Days
If under 24 hours
Hours
.. Minutes
13 Usual
Occupation :
Retired P.O. Clerk
(Kind of work done during most of working life)
14 Industry
or Business :
U.S. Postal Service
15 Social Security No.
None.
Tyrone
16 BIRTHPLACE (City)
(State or country)
Ireland
17 NAME OF
FATHER
Edward Conway
18 BIRTHPLACE OF
FATHER (City)
Tyrone
(State or country)
Ireland
19 MAIDEN NAME
(Signed)
Charles Liberan
M. D.
OF MOTHER
Catherine Cullinin
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
November 18,
19
63
7 NAME OF
FUNERAL, DIRECTOR
Arthur J. O'Maley
Winthrop, Mass
ADDRESS
Received and filed
NOV 18 1963
19
(Registrar)
PARENTS
21
Informant
(Address)
Anastasia .Conway.
Belcher St. Winthrop
1 HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
Health officer
november 18, 1963
(Official Designatign) &
(Date of Issue of Permit)
TUE.V
R-301A 1
ERik the $ CTIONS R ERTIFICATE
ving F DEATH enter an one or each ) and (c)
not mean of dying, art failure. c. It means OT compli- ich caused
, if any, De rise to use
-
(a), se under- use last.
ons contrib- ath but not he terminal lition given C.
hapter 137, 4. requires to print or cause or death on ficates, and , Acts of ires Physi- int or type signature.
9-925686
3 DATE OF
NOV
DEATH
(Month)
(Day)
(Year)
4 L
et
1962, 5
I last saw he walive on
11/15/
1963
Ida If married, widow Hetasia Butler
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Due To (b)
Due To (c)
OTHER
Cerebral Arteriosclerosis
CONDITIONS Cerebro Vascular Thrombosis
5 yrs. 6 mos
Was autopsy performed?
100
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased NO If so, specify
CHARLES
LIBERMAN
(PRINT OR TYPE SIGNATURE)
(Address) Wi Winthrop, Mass Date ...... 11/15/ 19 63
St.
Joseph's
West Roxbury
20 BIRTHPLACE OF
Tyrone
MOTHER (City)
(State or country)
Ireland
To be filed for burial permit with Board of Health or its Agent.
No
(Was deceased a
U. S. War Veteran,
[if so specify WAR)
(Usual place of abode)
15
1963
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TOW.
11 12
C)
ERK
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disea0%/ 1 81963 AM related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
5
6
IN
(THROP
RM R-301
burial permit d of Health Agent. CTIONS
OR CERTIFICATE
R TYPE R CAUSES EATH t enter han one for each b) and (c)
s not mean of dying, eart failure, tc. It means . OT compli- hich caused
ss, if any, ve rise to ause (a), the under- ause last.
ions contrib- eath but not the terminal dition given
X - PLACE OF DEATH
SUFFOLK (County)
WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
235
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
DeCOURCEY, ..... BabyGirl
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
(a) Residence. No ....
115 Summit AVE. Winthrop
(Usual place of abode)
Length of stay : In place of death .......... years .......... months .......... days. In place of residence .......... years .......... months ......
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
3
10 SINGLE
MARRIED
(write the word) single
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Husband's name in full)
12
AGE.
......... Years ..
Months.
.Days
If under 24 hours
.Hours. /5 Minutes
13 Usual Occupation : (Kind of work done during most working life)
14 Industry or Business :
15 Social Security No.
16 BIRTHPLACE (City).
(State or country )
17 NAME OF
FATHER
Richard D DeCOURCEY
18 BIRTHPLACE OF
FATHER (City) WINTHROP, MASS
(State or country)
19 MAIDEN NAME
OF MOTHER
JEANNE A. VIENNEAU
20 BIRTHPLACE OF MOTHER (City) .. (State or country)
WORCESTER, MASS
2I Informant
RICHARD D. DeCOURCEY
( Address)
115 SUMMIT AVE WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : · Parpoh &. Sirianni (6)
(Signature of Agent of Board of Health or other) Health officer
Diovember 15 1963
(Official Designation) / (Date of Issue of Permit)
A TRUE COPY ATTEST:
1
(If nonresident, give city or town and State)
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Day)
November
15,
1963
(Year)
4 I HEREBY CERTIFY
That I attended deceased from
nov.15
19 63
to .......
nov.15
1963
I last saw hEAlive on
11/15
..... 19 6 death is said to
have occurred on the date stated above, at 10- Am
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
PREMATURITY-50
(a)
Due To
PLACENTA ABRUPTIO -
PARTIAL
121ths
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
M. D.
MYRON N. KING MID
(Print or Type Name)
(Address) ILLPLEASANTST Date.
nov. 15 ,63'. WINTHALER
WINTHROP CEMETERY 6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL
NOVEMBER
15
063
7 NAME OF
FUNERAL DIRECTOR
Richel C. KIRBY INC
917 BENNINGTON ST. EAST BOSTON
Received and filed
NOV 15-1963
19.
(Registrar)
-932382
No.
WINTHROP COMMUNITY HOSPITAL
Registered No.
WINTHROP, MASS.
PARENTS
DIVORCED UNKNOWN
(Give maiden name of wife in full)
INTERVAL BETWEEN ONSET AND DEATH 2 HRS
(b)
(Month)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
12
THROR
NOV 1 5196
RM R-304
X 1
PLACE OF DELIVERY No.
SUFFOLK (County )
WINTHROP
(City or Town)
WINTHROP COMMUNITY HOSPITAL
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)
To be filed for burial permit with Board of Health or its Agent.
Registered No.
236
(If death occurred in a hospital or institution, 3
3 DATE OF
DELIVERY
11/15/63
(Month )
(Day)
(Year )
4 SEX
X
Male .. .. Female ...
.. Undetermined
5 COLOR (if
determined)
W
6 THIS BIRTH (Check one)
Single ..
. Twin
Triplet.
7 IF MULTIPLE BIRTH, BORN :
1st .. . . . 2nd
3rd
FATHER
MOTHER
14
MAIDEN NAME
MARGARET F CROWLEY
PRESENT NAME
MARGARET F PEARCE
9
RESIDENCE, NO. 93 CLIFF AVE
CITY OR TOWN
WINTHROP
STREET
STATE MASS
RESIDENCE,
93 CLIFF AVE
CITY OR TOWN WINTHROP
STREET
STATE MASS
10 COLOR OR
RACE.
WHITE
11 AGE AT TIME OF
THIS DELIVERY
26
(Years)
16 COLOR OR
RACE.
WHITE
17 AGE AT TIME OF
THIS DELIVERY
( Years)
12 PLACE OF WINT HROP.
BIRTH
(City or Town)
MAS
(State or country)
18 PLACE OBSOMENSTILLE
BIRTH
(City or Town)
MUSS
(State or country )
13 OCCUPATION MC 04. 2010 il INSPECTOR
19
INFORMANT
ROLAND
PEARCE
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus
pone
(a) How many children are
now living?
home
(b) How many children were
born alive but are now
dead ?
none
(c) How many previous fetal deaths of ANY gestation age ?
21 LENGTH OF
PREGNANCY
completed weeks
36
22 Weight Lb.//
OF FETUS
(or
Oz. Grams)
23 WHEN DID EETUS DIE?
Before
Labor
During Labor or Delivery Unknown
24 AUTOPSY Yes
No
25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE Umbilical cord assumed (a)
Due To (b)
Due To (c)
OTHER SIGNIFICANT
CONDITIONS
none
26
WINTHROP
Place of Burial or Cremation
WINTHROP.
(City or Town)
DATE OF BURIAL
NOV 18
1963
27
NAME OF
FUNERAL DIRECTOR MAURICE W KIRBY
ADDRESS
WINTHROP.
Received and filed
NOV 18 1963
19
( Registrar )
A TRUE COPY ATTEST :
I HEREBY CERTIFY that this delivery occurred on the date stated 10.00 Am .. and product of conception was not a live birth. above at
Signature of Attending Physician or Medical Examiner : peper Stregone Joseph GREGORIE (PRINT OR TYPE NAME) 19 4 Washington QUE Address Winthrop
M.D.
Date 11/10-1963
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :
Paeph E Lireanna (3) (Signature of Agent of Board of ffealth or other ) Health officer nov18,1963
( Official Designation )
(Date of Issue of Permit )
In giving AUSE OF TAL DEATH o not enter ore than one use for each of (a), (b) and (c)
l or maternal lition causing l death (do use such is as stillbirth prematurity.) l and/or ma- al conditions. y, which gave e to above e (a), stating underlying e last.
ditions of fetus mother which have contrib- d to fetal th, but, in so as is known, e not related cause given (a).
10M-6-62-933404
2 NAME OF FETUS
(if given)
PEARCE , MALE
St.
give its NAME instead of street and number)
8
FULL
NAME
ROLAND PEARCE
FETAL DEATH
OF TOW; il 12. 1 i
SLEFFS
6
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48, ACTS OF 1960.
Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, .. . shall not be permitted except ... ".
Section 9A. When a child is born dead, after a period of genouoh 81960 AHss than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.
Section 12. ". .. No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."
Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.
RM R-301
I
PLACE OF DEATH
SUFFOLK
(County)
WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. 232
[(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
George Pappas
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
720
(a)
Residence. No.
42 Franklin Street
(Usual place of abode)
.. St .. Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.
2 days. In place of residence 2 years. ...... months. days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIEDA
WIDOWED
DIVORCED
UNKNOWN
(write the word)
: married
11 If married, widowed! or divorced HUSBAND of
PAGONA SAGOULAS PAPPAS (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE. Years.
- Months.
Days
If under 24 hours
.Hours ........ Minutes
13 Usual Clu
Occupation :
RESTAURANT PROP.
(Kind of work done during most working life)
14 Industry
or Business :
Food
15 Social Security No ...
217-28-0025
MessIniA
GREECE
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
GEORGE PAPPAS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
messinia
GREECE
19 MAIDEN NAME
OF MOTHER
KATERINA STAVRIAniA
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
GREECE
MRS PAGONA PAPPAS
(wife)
42 FRANKLIN St. WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Tripoli 6 Lereanna (1)
(Signature of Agent of Board of Health or other)
Health Oficer
november 19.1963
(Official Designation)
(Date of Issue of Permit)
1X
A TRUE COPY ATTEST:
INTERVAL BETWEEN ONSET AND DEATH 15 mos
(a) ...
Due To
(b)
Metastatic Cancer of
Due (c) Esophagus and right/Lang from primary in left cur SIGNIFICANT 0 CONDITIONS
Tyr
Left Theumonectomy l' 1 gr.
Was autopsy performed?
What test confirmed diagnosi
Clinical operative pattolage
5 Was disease or injury in any way related to occupation of deceased ?/Vol If so, specify ....
(Signature)
Charles Liberman
., M. D.
CHARLES
LIBERMAN
(Print or Type Name)
(Address)
WINTHROP MASS Date 11/16/1963
WINTHROP CEMETERY WINTHROP 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
JUAVRiST MAURiS
Cluster
ADDRESS 48 0. Common St. Lynn
19
Received and filed
NOV 19 1963
( Registrar )
932382
r burial permit d of Health Agent. CTIONS R ERTIFICATE
R TYPE CAUSES ATH enter an one or each ) and (c)
not mean of dying, art failure, c. It means or compli- ich caused
s, if any, ve rise to use (a), he under- use last.
ons contrib- ath but not he terminal dition given
X
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Nov
16
1963
(Month)
(Day)
(Year)
YTHEREBY CERTIFY, That I attended deceased from 4 Llug
19.62
to ...
Now: 16,
1963
I last say hl.malive on
Nov. 16.
19.63 death is said to
have occurred on the date stated above, at
7:30 p.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cancer of Lurna
WIN HROF COMMUNITY HOSPITAL
No
7 NAME OF FUNK FAL MIRECTOR
Nov. 19
63
19.
PARENTS
MESSiniA
21 Informant
( Address)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : (1) Attending physicians will certify to such deaths only as those of persons 150 to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of- persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
TOW
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly. by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related To occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
12
MINY
CLERK
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
6
THROP.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the odoldas tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
191963 PM
-
X 1 PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
238
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
Pasquale Graziose
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
4 Billerica Street
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death .......... years ..
3 monthsdays. In place of residence: 25 ve
.years
....... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCEDdivorced
UNKNOWN
11 If married, widowed, or divorced
Esther Calo
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE.78
2 days
Years ..
Months.
Days
Retired
13 Usual
Occupation
(Kind of work done during most of working life)
14 Industry or Business .. *****
15 Social Security No ....
017-14-5431
16 BIRTHPLACE (City).
(State or country )
Italy
17 NAME OF
FATHER
Engene Graziose
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country )
Italy
19 MAIDEN NAME
OF MOTHER
Maria (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
21 Informant
Eugene Graziose (10n)
(Addr
4 Sycamore Circle, W. Peabody, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: L'apl 6 Liveanne (A)
(Signature of Agent of Board of Health or other)
Health Officer
november 19, 1963
(Official Designation)
(Date of Issue of Permit)
X
A TRUE COPY ATTEST:
(Registrar )
male
4 I HEREBY CERTIFY, That I attended deceased from
Sept 24
.. , 1963
to ..
NOV. 17
63
I last saw hlualive on
NOV.16
196 2 death is said to
have occurred on the date stated above, at
9:15Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Bronchopneumonia
INTERVAL BETWEEN ONSET AND DEATH
Due To
(b)
Due To
(c)
-
OTHER
SIGNIFICANT
CONDITIONS
Pulmonary fibrosis
Was autopsy performed?
NO
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
NO
(Signature)
Chela 1. Ferrera
M. D.
Charles J. Ferrera, M.D
(Print or Typs Name)
(ASHe Bennington St, E. Boston 11/18
19 63
St. Michael Cemetery
Boston
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Nov. 20,
19.
63
7 NAME OF
FUNERAL DIRECTOR
Vincent R. Rapino
9 Chelsea St., East Boston, Mass.
ADDRESS
Received and filed
NOV 19 1963
19
2-934553
RM R-301
r burial permit 'd of Health Agent. CTIONS OR ERTIFICATE
R TYPE CAUSES CATH enter han one or each ) and (c)
s not mean of dying, cart failure, c. It means . of compli- ich caused
s, if any, ve rise to use (a), he under- use last.
ions contrib- ath but not the terminal dition given
BESTEN 12-5-63
Bay View Nursing Home No
(City or Town making this return)
(Was deceased a
U. S. War Veteran,
no
if so specify WAR)
Boston
St.
(City or town and State)
3 DATE OF
DEATH
November 17, 1963
(Month)
(Day)
(Year)
(write the word)
If under 24 hours
Hours ........ Minutes
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
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